Evaluation of prognostic risk models for postoperative pulmonary complications in adult patients undergoing major abdominal surgery: a systematic review and international external validation cohort study
Authors: O Kouli, V Murray, S Bhatia, WA Cambridge, M Kawka, S Shafi, SR Knight, SK Kamarajah, KA McLean, JC Glasbey, RA Khaw, W Ahmed, M Akhbari, D Baker, A Borakati, E Mills, R Thavayogan, I Yasin, K Raubenheimer, W Ridley, M Sarrami, G Zhang, N Egoroff, P Pockney, T Richards, A Bhangu, B Creagh-Brown, M Edwards, EM Harrison, M Lee, D Nepogodiev, T Pinkney, R Pearse, N Smart, R Vohra, C Sohrabi, A Jamieson, M Nguyen, A Rahman, C English, L Tincknell, P Kakodkar, I Kwek, N Punjabi, J Burns, S Varghese, M Erotocritou, S McGuckin, S Vayalapra, E Dominguez, J Moneim, M Salehi, HL Tan, A Yoong, L Zhu, B Seale, Z Nowinka, N Patel, B Chrisp, J Harris, I Maleyko, F Muneeb, M Gough, CE James, O Skan, A Chowdhury, N Rebuffa, H Khan, B Down, Q Fatimah Hussain, M Adams, A Bailey, G Cullen, YXJ Fu, B McClement, A Taylor, S Aitken, B Bachelet, J Brousse de Gersigny, C Chang, B Khehra, N Lahoud, M Lee Solano, M Louca, P Rozenbroek, E Rozitis, N Agbinya, E Anderson, G Arwi, I Barry, C Batchelor, T Chong, LY Choo, L Clark, M Daniels, J Goh, A Handa, J Hanna, L Huynh, A Jeon, A Kanbour, A Lee, J Lee, T Lee, J Leigh, D Ly, F McGregor, J Moss, M Nejatian, E O'Loughlin, I Ramos, B Sanchez, A Shrivathsa, A Sincari, S Sobhi, R Swart, J Trimboli, P Wignall, E Bourke, A Chong, S Clayton, A Dawson, E Hardy, R Iqbal, L Le, S Mao, I Marinelli, H Metcalfe, D Panicker, HH R, S Ridgway, HH Tan, S Thong, M Van, S Woon, XS Woon-Shoo-Tong, S Yu, K Ali, J Chee, C Chiu, YW Chow, A Duller, P Nagappan, S Ng, M Selvanathan, C Sheridan, M Temple, JE Do, NN Dudi-Venkata, E Humphries, L Li, LT Mansour, C Massy-Westropp, B Fang, K Farbood, H Hong, Y Huang, M Joan, C Koh, YHA Liu, T Mahajan, E Muller, R Park, M Tanudisastro, JJG Wu, P Chopra, S Giang, S Radcliffe, P Thach, D Wallace, A Wilkes, SH Chinta, J Li, J Phan, F Rahman, A Segaran, J Shannon, M Zhang, N Adams, A Bonte, A Choudhry, N Colterjohn, JA Croyle, J Donohue, A Feighery, A Keane, D McNamara, K Munir, D Roche, R Sabnani, D Seligman, S Sharma, Z Stickney, H Suchy, R Tan, S Yordi, I Ahmed, M Aranha, D El Sabawy, P Garwood, M Harnett, R Holohan, R Howard, Y Kayyal, N Krakoski, M Lupo, W McGilberry, H Nepon, Y Scoleri, C Urbina, MF Ahmad Fuad, O Ahmed, D Jaswantlal, E Kelly, MHT Khan, D Naidu, WX Neo, R O'Neill, M Sugrue, JD Abbas, S Abdul-Fattah, A Azlan, K Barry, NS Idris, N Kaka, D Mc Dermott, MN Mohammad Nasir, M Mozo, A Rehal, M Shaikh Yousef, RH Wong, E Curran, M Gardner, A Hogan, R Julka, G Lasser, N Ní Chorráin, J Ting, R Browne, S George, Z Janjua, V Leung Shing, M Megally, S Murphy, L Ravenscroft, A Vedadi, V Vyas, A Bryan, A Sheikh, J Ubhi, K Vannelli, A Vawda, L Adeusi, C Doherty, C Fitzgerald, H Gallagher, P Gill, H Hamza, M Hogan, S Kelly, J Larry, P Lynch, NA Mazeni, R O'Connell, R O'Loghlin, K Singh, R Abbas Syed, A Ali, B Alkandari, A Arnold, E Arora, R Azam, C Breathnach, J Cheema, M Compton, S Curran, JA Elliott, O Jayasamraj, N Mohammed, A Noone, A Pal, S Pandey, P Quinn, R Sheridan, L Siew, EP Tan, SW Tio, VTR Toh, M Walsh, C Yap, J Yassa, T Young, N Agarwal, SA Almoosawy, K Bowen, D Bruce, R Connachan, A Cook, A Daniell, M Elliott, HKF Fung, A Irving, S Laurie, YJ Lee, ZX Lim, S Maddineni, RE McClenaghan, V Muthuganesan, P Ravichandran, N Roberts, S Shaji, S Solt, E Toshney, C Arnold, O Baker, F Belais, C Bojanic, M Byrne, CYC Chau, S De Soysa, M Eldridge, M Fairey, N Fearnhead, A Guéroult, JSY Ho, K Joshi, N Kadiyala, S Khalid, F Khan, K Kumar, E Lewis, J Magee, D Manetta-Jones, S Mann, L McKeown, C Mitrofan, T Mohamed, A Monnickendam, AYKC Ng, A Ortu, M Patel, T Pope, S Pressling, K Purohit, S Saji, J Shah Foridi, R Shah, SS Siddiqui, K Surman, M Utukuri, A Varghese, CYK Williams, JJ Yang, E Billson, E Cheah, P Holmes, S Hussain, D Murdock, A Nicholls, P Patel, G Ramana, M Saleki, H Spence, D Thomas, C Yu, M Abousamra, C Brown, I Conti, A Donnelly, M Durand, N French, R Goan, E O'Kane, P Rubinchik, H Gardiner, B Kempf, YL Lai, H Matthews, E Minford, C Rafferty, C Reid, N Sheridan, T Al Bahri, N Bhoombla, BM Rao, L Titu, S Chatha, C Field, T Gandhi, R Gulati, R Jha, MT Jones Sam, S Karim, R Patel, M Saunders, K Sharma, S Abid, E Heath, D Kurup, A Patel, M Ali, B Cresswell, D Felstead, K Jennings, T Kaluarachchi, L Lazzereschi, H Mayson, JE Miah, B Reinders, A Rosser, C Thomas, H Williams, Z Al-Hamid, L Alsadoun, M Chlubek, P Fernando, E Gaunt, Y Gercek, R Maniar, R Ma, M Matson, S Moore, A Morris, PG Nagappan, M Ratnayake, L Rockall, O Shallcross, A Sinha, KE Tan, S Virdee, R Wenlock, HA Donnelly, R Ghazal, I Hughes, X Liu, M McFadden, E Misbert, P Mogey, A O'Hara, C Peace, C Rainey, P Raja, M Salem, J Salmon, CH Tan, D Alves, S Bahl, C Baker, J Coulthurst, K Koysombat, T Linn, P Rai, A Sharma, A Shergill, M Ahmed, S Ahmed, LH Belk, H Choudhry, D Cummings, Y Dixon, C Dobinson, J Edwards, J Flint, C Franco Da Silva, R Gallie, M Gardener, T Glover, M Greasley, A Hatab, R Howells, T Hussey, A Khan, A Mann, H Morrison, A Ng, R Osmond, N Padmakumar, F Pervaiz, R Prince, A Qureshi, R Sawhney, B Sigurdson, L Stephenson, K Vora, A Zacken, P Cope, R Di Traglia, I Ferarrio, N Hackett, R Healicon, L Horseman, LI Lam, M Meerdink, D Menham, R Murphy, I Nimmo, A Ramaesh, J Rees, R Soame, N Dilaver, D Adebambo, E Brown, J Burt, K Foster, L Kaliyappan, P Knight, A Politis, E Richardson, J Townsend, M Abdi, M Ball, S Easby, N Gill, E Ho, H Iqbal, M Matthews, S Nubi, JO Nwokocha, I Okafor, G Perry, B Sinartio, N Vanukuru, D Walkley, T Welch, J Yates, N Yeshitila, K Bryans, B Campbell, C Gray, R Keys, M Macartney, G Chamberlain, A Khatri, A Kucheria, STP Lee, G Reese, J Roy choudhury, WYR Tan, JJ Teh, A Ting, S Kazi, C Kontovounisios, K Vutipongsatorn, T Amarnath, N Balasubramanian, E Bassett, P Gurung, J Lim, A Panjikkaran, A Sanalla, M Alkoot, V Bacigalupo, N Eardley, M Horton, A Hurry, C Isti, P Maskell, K Nursiah, G Punn, H Salih, E Epanomeritakis, A Foulkes, R Henderson, E Johnston, H McCullough, M McLarnon, E Morrison, A Cheung, SH Cho, F Eriksson, J Hedges, Z Low, C May, L Musto, S Nagi, S Nur, E Salau, S Shabbir, MC Thomas, L Uthayanan, S Vig, M Zaheer, G Zeng, S Ashcroft-Quinn, R Brown, J Hayes, R McConville, R French, A Gilliam, S Sheetal, MU Shehzad, W Bani, I Christie, J Franklyn, M Khan, J Russell, S Smolarek, R Varadarassou, SK Ahmed, S Narayanaswamy, J Sealy, M Shah, V Dodhia, A Manukyan, R O'Hare, J Orbell, I Chung, K Forenc, A Gupta, A Agarwal, A Al Dabbagh, R Bennewith, J Bottomley, TSM Chu, YYA Chu, W Doherty, B Evans, P Hainsworth, T Hosfield, CH Li, I McCullagh, A Mehta, A Thaker, B Thompson, A Virdi, H Walker, E Wilkins, C Dixon, MR Hassan, N Lotca, KS Tong, H Batchelor-Parry, S Chaudhari, T Harris, J Hooper, C Johnson, C Mulvihill, J Nayler, O Olutobi, B Piramanayagam, K Stones, M Sussman, C Weaver, F Alam, M Al Rawi, F Andrew, A Arrayeh, N Azizan, A Hassan, Z Iqbal, I John, M Jones, O Kalake, M Keast, J Nicholas, A Patil, K Powell, P Roberts, A Sabri, AK Segue, A Shah, SA Shaik Mohamed, A Shehadeh, S Shenoy, A Tong, M Upcott, D Vijayasingam, S Anarfi, J Dauncey, A Devindaran, P Havalda, G Komninos, E Mwendwa, C Norman, J Richards, A Urquhart, J Allan, E Cahya, H Hunt, C McWhirter, R Norton, C Roxburgh, JY Tan, S Ali Butt, S Hansdot, I Haq, A Mootien, I Sanchez, T Vainas, E Deliyannis, M Tan, M Vipond, NN Chittoor Satish, A Dattani, L De Carvalho, M Gaston-Grubb, L Karunanithy, B Lowe, C Pace, K Raju, J Roope, C Taylor, H Youssef, T Munro, C Thorn, KHF Wong, A Yunus, S Chawla, A Datta, AA Dinesh, D Field, T Georgi, A Gwozdz, E Hamstead, N Howard, N Isleyen, N Jackson, J Kingdon, KS Sagoo, A Schizas, L Yin, E Aung, YY Aung, S Franklin, SM Han, WC Kim, A Martin Segura, M Rossi, T Ross, R Tirimanna, B Wang, O Zakieh, H Ben-Arzi, A Flach, E Jackson, S Magers, C Olu abara, E Rogers, K Sugden, H Tan, S Veliah, U Walton, A Asif, Y Bharwada, D Bowley, A Broekhuizen, L Cooper, N Evans, H Girdlestone, C Ling, H Mann, N Mehmood, CL Mulvenna, N Rainer, I Trout, R Gujjuri, D Jeyaraman, E Leong, D Singh, E Smith, J Anderton, M Barabas, S Goyal, D Howard, A Joshi, D Mitchell, T Weatherby, R Badminton, R Bird, D Burtle, NY Choi, K Devalia, E Farr, F Fischer, J Fish, F Gunn, D Jacobs, P Johnston, A Kalakoutas, E Lau, YNAF Loo, H Louden, N Makariou, K Mohammadi, Y Nayab, S Ruhomaun, R Ryliskyte, M Saeed, P Shinde, M Sudul, K Theodoropoulou, J Valadao-Spoorenberg, F Vlachou, SR Arshad, AM Janmohamed, M Noor, O Oyerinde, A Saha, Y Syed, W Watkinson, H Ahmadi, A Akintunde, A Alsaady, J Bradley, D Brothwood, M Burton, M Higgs, C Hoyle, C Katsura, R Lathan, A Louani, R Mandalia, AS Prihartadi, B Qaddoura, L Sandland-Taylor, S Thadani, A Thompson, J Walshaw, S Teo, S Ali, JH Bawa, S Fox, K Gargan, SA Haider, N Hanna, A Hatoum, Z Khan, AM Krzak, T Li, J Pitt, GJS Tan, Z Ullah, E Wilson, J Cleaver, J Colman, L Copeland, A Coulson, P Davis, H Faisal, F Hassan, JT Hughes, Y Jabr, F Mahmoud Ali, ZN Nahaboo Solim, A Sangheli, S Shaya, R Thompson, H Cornwall, M De Andres Crespo, E Fay, J Findlay, E Groves, O Jones, A Killen, J Millo, S Thomas, J Ward, M Wilkins, F Zaki, E Zilber, K Bhavra, A Bilolikar, M Charalambous, A Elawad, A Eleni, R Fawdon, A Gibbins, D Livingstone, D Mala, SE Oke, D Padmakumar, MA Patsalides, D Payne, C Ralphs, A Roney, N Sardar, K Stefanova, F Surti, R Timms, G Tosney, J Bannister, NS Clement, V Cullimore, F Kamal, J Lendor, J McKay, J Mcswiggan, N Minhas, K Seneviratne, S Simeen, J Valverde, N Watson, I Bloom, TH Dinh, J Hirniak, R Joseph, M Kansagra, CKN Lai, N Melamed, J Patel, J Randev, T Sedighi, B Shurovi, J Sodhi, N Vadgama, S Abdulla, B Adabavazeh, A Champion, R Chennupati, K Chu, S Devi, A Haji, J Schulz, F Testa, P Davies, B Gurung, S Howell, P Modi, A Pervaiz, M Zahid, S Abdolrazaghi, R Abi Aoun, Z Anjum, G Bawa, R Bhardwaj, S Brown, M Enver, D Gill, D Gopikrishna, D Gurung, A Kanwal, P Kaushal, A Khanna, E Lovell, C McEvoy, M Mirza, S Nabeel, S Naseem, K Pandya, R Perkins, R Pulakal, M Ray, C Reay, S Reilly, A Round, J Seehra, NM Shakeel, B Singh, M Vijay Sukhnani, L Brown, B Desai, H Elzanati, J Godhaniya, E Kavanagh, J Kent, A Kishor, A Liu, M Norwood, N Shaari, C Wood, M Wood, A Brown, A Chellapuri, A Ferriman, I Ghosh, N Kulkarni, T Noton, A Pinto, S Rajesh, B Varghese, C Wenban, R Aly, C Barciela, T Brookes, E Corrin, M Goldsworthy, MS Mohamed Azhar, J Moore, S Nakhuda, D Ng, S Pillay, S Port, M Abdullah, J Akinyemi, S Islam, A Kale, A Lewis, T Manjunath, H McCabe, S Misra, T Stubley, JP Tam, N Waraich, T Chaora, C Ford, I Osinkolu, G Pong, J Rai, R Risquet, J Ainsworth, P Ayandokun, E Barham, G Barrett, J Barry, E Bisson, I Bridges, D Burke, J Cann, M Cloney, S Coates, P Cripps, C Davies, N Francis, S Green, G Handley, D Hathaway, L Hurt, S Jenkins, C Johnston, A Khadka, U McGee, D Morris, R Murray, C Norbury, Z Pierrepont, C Richards, O Ross, A Ruddy, C Salmon, M Shield, K Soanes, N Spencer, S Taverner, C Williams, W Wills-Wood, S Woodward, J Chow, J Fan, O Guest, I Hunter, WY Moon, S Arthur-Quarm, P Edwards, V Hamlyn, L 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Odunukwe, G Preest, F Raheel, A Rajaseharan, A Ramgopal, C Risbrooke, K Selvaratnam, G Sethunath, R Tabassum, J Taylor, A Thakker, N Wijesingha, R Wybrew, T Yasin, A Ahmed Osman, S Alfadhel, E Carberry, JY Chen, I Drake, P Glen, N Jayasuriya, L Kawar, R Myatt, LOH Sinan, SSY Siu, V Tjen, O Adeboyejo, H Bacon, R Barnes, C Birnie, A D'Cunha Kamath, E Hughes, S Middleton, R Owen, E Schofield, C Short, R Smith, H Wang, M Willett, M Zimmerman, J Balfour, T Chadwick, M Coombe-Jones, HP Do Le, G Faulkner, K Hobson, Z Shehata, M Beattie, G Chmielewski, C Chong, B Donnelly, B Drusch, J Ellis, C Farrelly, J Feyi-Waboso, I Hibell, L Hoade, C Ho, H Jones, B Kodiatt, P Lidder, L Ni Cheallaigh, R Norman, I Patabendi, H Penfold, M Playfair, S Pomeroy, C Ralph, H Rottenburg, J Sebastian, M Sheehan, V Stanley, J Welchman, D Ajdarpasic, A Antypas, O Azouaghe, S Basi, G Bettoli, S Bhattarai, L Bommireddy, K Bourne, J Budding, R Cookey-Bresi, T Cummins, G Davies, C Fabelurin, R Gwilliam, J Hanley, A Hird, 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Brazier, L Carroll, A Goede, A Harbourne, A Lakhani, M Lami, J Larwood, J Martin, J Merchant, S Pattenden, A Pradhan, N Raafat, E Rothwell, Y Shammoon, R Sudarshan, E Vickers, L Wingfield, I Ashworth, S Azizi, R Bhate, T Chowdhury, A Christou, L Davies, M Dwaraknath, Y Farah, J Garner, E Gureviciute, E Hart, A Jain, S Javid, HK Kankam, P Kaur Toor, R Kaz, M Kermali, I Khan, A Mattson, A McManus, M Murphy, K Nair, D Ngemoh, E Norton, A Olabiran, L Parry, T Payne, K Pillai, S Price, K Punjabi, A Raghunathan, A Ramwell, M Raza, J Ritehnia, G Simpson, W Smith, S Sodeinde, L Studd, M Subramaniam, J Thomas, S Towey, E Tsang, D Tuteja, J Vasani, M Vio, A Badran, J Adams, J Anthony Wilkinson, S Asvandi, T Austin, A Bald, E Bix, M Carrick, B Chander, S Chowdhury, B Cooper Drake, S Crosbie, S D Portela, D Francis, C Gallagher, R Gillespie, H Gravett, P Gupta, C Ilyas, G James, J Johny, A Jones, F Kinder, C MacLeod, C Macrow, A Maqsood-Shah, J Mather, L McCann, R McMahon, E Mitham, M Mohamed, E Munton, K Nightingale, K O'Neill, I Onyemuchara, R Senior, A Shanahan, J Sherlock, A Spyridoulias, C Stavrou, D Stokes, R Tamang, E Taylor, C Trafford, C Uden, C Waddington, D Yassin, M Zaman, S Bangi, T Cheng, D Chew, N Hussain, S Imani-Masouleh, G Mahasivam, G McKnight, HL Ng, HC Ota, T Pasha, W Ravindran, K Shah, S Vishnu K, S Zaman, W Carr, S Cope, EJ Eagles, M Howarth-Maddison, CY Li, J Reed, A Ridge, T Stubbs, D Teasdaled, R Umar, J Worthington, A Dhebri, R Kalenderov, A Alattas, Z Arain, R Bhudia, D Chia, S Daniel, T Dar, H Garland, M Girish, A Hampson, H Kyriacou, K Lehovsky, W Mullins, N Omorphos, N Vasdev, A Venkatesh, W Waldock, A Bhandari, G Brown, G Choa, CE Eichenauer, K Ezennia, Z Kidwai, A Lloyd-Thomas, A Macaskill Stewart, C Massardi, E Sinclair, N Skajaa, M Smith, I Tan, N Afsheen, A Anuar, Z Azam, P Bhatia, N Davies-kelly, S Dickinson, M Elkawafi, M Ganapathy, S Gupta, EG Khoury, D Licudi, V Mehta, S Neequaye, G Nita, VL Tay, S Zhao, E Botsa, H Cuthbert, J Elliott, M 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Wales, H Waring, M Wu, T Yang, TTS Ye, A Zander, C Zeicu, S Bellam, J Francombe, N Kawamoto, MR Rahman, A Sathyanarayana, HT Tang, J Cheung, J Hollingshead, V Page, J Sugarman, E Wong, J Chiong, E Fung, SY Kan, J Kiang, J Kok, O Krahelski, MY Liew, B Lyell, Z Sharif, D Speake, L Alim, NY Amakye, J Chandrasekaran, N Chandratreya, J Drake, T Owoso, YM Thu, B Abou El Ela Bourquin, J Alberts, D Chapman, N Rehnnuma, K Ainsworth, H Carpenter, T Emmanuel, T Fisher, M Gabrel, Z Guan, S Hollows, A Hotouras, N Ip Fung Chun, S Jaffer, G Kallikas, N Kennedy, B Lewinsohn, FY Liu, S Mohammed, A Rutherfurd, T Situ, A Stammer, F Taylor, N Thin, E Urgesi, N Zhang, MA Ahmad, A Bishop, A Bowes, A Dixit, R Glasson, S Hatta, K Hatt, S Larcombe, J Preece, E Riordan, D Fegredo, MZ Haq, C Li, G McCann, D Stewart, W Baraza, D Bhullar, G Burt, J Coyle, J Deans, A Devine, R Hird, O Ikotun, G Manchip, C Ross, L Storey, WWL Tan, C Tse, C Warner, M Whitehead, F Wu, EL Court, E Crisp, M Huttman, F Mayes, H Robertson, H Rosen, C Sandberg, H Smith, M Al Bakry, W Ashwell, S Bajaj, D Bandyopadhyay, O Browlee, S Burway, CP Chand, K Elsayeh, A Elsharkawi, E Evans, S Ferrin, A Fort-Schaale, M Iacob, K I, G Impelliziere Licastro, AS Mankoo, T Olaniyan, J Otun, R Pereira, R Reddy, D Saeed, O Simmonds, G Singhal, K Tron, C Wickstone, R Williams, E Bradshaw, V De Kock Jewell, C Houlden, C Knight, H Metezai, A Mirza-Davies, Z Seymour, D Spink, S Wischhusen
Journal: The Lancet Digital Health (2022)

Stratifying risk of postoperative pulmonary complications after major abdominal surgery allows clinicians to modify risk through targeted interventions and enhanced monitoring. In this study, we aimed to identify and validate prognostic models against a new consensus definition of postoperative pulmonary complications.We did a systematic review and international external validation cohort study. The systematic review was done in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched MEDLINE and Embase on March 1, 2020, for articles published in English that reported on risk prediction models for postoperative pulmonary complications following abdominal surgery. External validation of existing models was done within a prospective international cohort study of adult patients (≥18 years) undergoing major abdominal surgery. Data were collected between Jan 1, 2019, and April 30, 2019, in the UK, Ireland, and Australia. Discriminative ability and prognostic accuracy summary statistics were compared between models for the 30-day postoperative pulmonary complication rate as defined by the Standardised Endpoints in Perioperative Medicine Core Outcome Measures in Perioperative and Anaesthetic Care (StEP-COMPAC). Model performance was compared using the area under the receiver operating characteristic curve (AUROCC).In total, we identified 2903 records from our literature search; of which, 2514 (86·6%) unique records were screened, 121 (4·8%) of 2514 full texts were assessed for eligibility, and 29 unique prognostic models were identified. Nine (31·0%) of 29 models had score development reported only, 19 (65·5%) had undergone internal validation, and only four (13·8%) had been externally validated. Data to validate six eligible models were collected in the international external validation cohort study. Data from 11 591 patients were available, with an overall postoperative pulmonary complication rate of 7·8% (n=903). None of the six models showed good discrimination (defined as AUROCC ≥0·70) for identifying postoperative pulmonary complications, with the Assess Respiratory Risk in Surgical Patients in Catalonia score showing the best discrimination (AUROCC 0·700 [95% CI 0·683-0·717]).In the pre-COVID-19 pandemic data, variability in the risk of pulmonary complications (StEP-COMPAC definition) following major abdominal surgery was poorly described by existing prognostication tools. To improve surgical safety during the COVID-19 pandemic recovery and beyond, novel risk stratification tools are required.British Journal of Surgery Society.